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ESC GUIDELINES

2013 ESC Guidelines on cardiac pacing and cardiac

resynchronization therapy: Addenda The Task Force on cardiac pacing and resynchronization therapy of the

European Society of Cardiology (ESC). Developed in collaboration

with the European Heart Rhythm Association (EHRA).

Authors/Task Force Members: Michele Brignole (Chairperson) (Italy)*,

Angelo Auricchio (Switzerland), Gonzalo Baron-Esquivias (Spain), Pierre Bordachar

(France), Giuseppe Boriani (Italy), Ole-A Breithardt (Germany), John Cleland (UK),

Jean-Claude Deharo (France), Victoria Delgado (Nertherlands), Perry M. Elliott (UK),Bulent Gorenek (Turkey), Carsten W. Israel (Germany), Christophe Leclercq

(France), Cecilia Linde (Sweden), Lluıs Mont (Spain), Luigi Padeletti (Italy),

Richard Sutton (UK), Panos E. Vardas (Greece)

ESC Committee for Practice Guidelines (CPG): Jose Luis Zamorano (Chairperson) (Spain), Stephan Achenbach

(Germany), Helmut Baumgartner (Germany), Jeroen J. Bax (Netherlands), Hector Bueno (Spain), Veronica Dean

(France), Christi Deaton (UK), Cetin Erol (Turkey), Robert Fagard (Belgium), Roberto Ferrari (Italy), David Hasdai

(Israel), Arno W. Hoes (Netherlands), Paulus Kirchhof (Germany/UK), Juhani Knuuti (Finland), Philippe Kolh

(Belgium), Patrizio Lancellotti (Belgium), Ales Linhart (Czech Republic), Petros Nihoyannopoulos (UK),

Massimo F. Piepoli (Italy), Piotr Ponikowski (Poland), Per Anton Sirnes (Norway), Juan Luis Tamargo (Spain),

Michal Tendera (Poland), Adam Torbicki (Poland), William Wijns (Belgium), Stephan Windecker (Switzerland)

Document Reviewers: Paulus Kirchhof (CPG Review Coordinator) (Germany/UK), Carina Blomstrom-Lundqvist

(CPG Review Coordinator) (Sweden), Luigi P. Badano (Italy), Farid Aliyev (Azerbaijan), Dietmar Ba ¨ nsch (Germany),

Helmut Baumgartner (Germany), Walid Bsata (Syria), Peter Buser (Switzerland), Philippe Charron (France),

Jean-Claude Daubert (France), Dan Dobreanu (Romania), Svein Faerestrand (Norway), David Hasdai (Israel),

Arno W. Hoes (Netherlands), Jean-Yves Le Heuzey (France), Hercules Mavrakis (Greece), Theresa McDonagh (UK),

Jose Luis Merino (Spain), Mostapha M. Nawar (Egypt), Jens Cosedis Nielsen (Denmark), Burkert Pieske (Austria),

Lidija Poposka (The Former Yug‘oslav Republic of Macedonia), Frank Ruschitzka (Switzerland), Michal Tendera

(Poland), Isabelle C. Van Gelder (Netherlands), Carol M. Wilson (Ireland)

The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines

* Corresponding author. Chairperson: Professor Michele Brignole, Department of Cardiology, Ospedali Del Tigullio, Via Don Bobbio 25, IT-16033 Lavagna, (GE) Italy. Tel: +39 0185

329 569, Fax: +39 0185 306 506, Email: [email protected]

& The European Society of Cardiology 2013. All rights reserved. For permissions please email: [email protected]

†Other ESC entities having participated in the development of this document:

Associations: Acute Cardiovascular Care Association (ACCA), Heart Failure Association (HFA), European Association of Cardiovascular Imaging (EACVI)

Working Groups: Myocardial and Pericardial Diseases

Council: Cardiology Practice

The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC

Guidelinesmay be translatedor reproducedin anyform without written permissionfrom theESC. Permissioncan be obtained uponsubmission of a written request to OxfordUniversity

Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC.

Disclaimer . The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health profes-

sionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of health profes-

sionals to makeappropriate decisions in the circumstances of theindividualpatients, in consultation withthat patient, andwhere appropriateand necessarythe patient’s guardianor carer.

It is also the health professional’s responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.

European Heart Journal

doi:10.1093/eurheartj/eht180

http://www.escardio.org/guidelines

mailto:[email protected]









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Keywords Cardiac pacing † Cardiac resynchronization therapy † Pacemaker † Heart failure † Syncope † Atrial

fibrillation

Web Figure1 Averageimplantation rateof pacemaker(PM) in the16 western European countries,Poland andCzech Republic (unitsper million

inhabitants) based on reports from major manufacturers. The figures include first implantations and replacements

Source: Eucomed (www.eucomed.org/medical-technology/facts-figures).w2

Web Figure6 Average implantation rateof devicesfor cardiac resynchronization therapy (CRT)in the 16 European countries (unitsper million

inhabitants) based on reports from major manufacturers. The figures include first implantations and replacements

Source: Eucomed (www.eucomed.org/medical-technology/facts-figures)w2

ESC GuidelinesPage 2 of 21



Web Figure 7 Relative risk of primary end-point (heart failure or death) by treatment (cardiac resynchronization therapy and defibrillator

(CRT-D) versus implantable cardioverter defibrillator (ICD) only according to selected clinical characteristics in patients with left bundle branch

block (LBBB; top) and non-LBBB patients (bottom) in the MADIT-CRT study (adapted from Zareba et alw354). Class I refers to New York Heart

Association classification; US¼United States patients; OUS¼outside United States patients

ESC Guidelines Page 3 of 21



Web Figure 9 Algorithm for atrioventricular and interventricular delay optimization. AV¼atrioventricular; CRT¼cardiac resynchronization

therapy; ECG¼electrocardiogram; LV¼left ventricular




Web Figure 11 Kaplan-Meier estimates of time to death of any cause during the follow-up period of .1 year(9 –15 months) in the European

CRT Survey.w355

Web Figure 12 Suggested optimal pacing mode in children (modified from van Geldorp I et alw204)




Web Table 3 Clinical characteristics and pacingmodality in patients treated by permanent pacing in the registries of the

some European national pacing societies w3-8

AVB¼atrioventricular block (includes I, II and III degree); AF¼atrial fibrillation; SSS¼sick sinus syndrome (includes reflex syncope); BBB¼bundle branch block.

Web Table 4 Causes of bradycardia

AV¼atrioventricular.

Web Table 5 Typical symptoms of bradycardia (SB

and AV block)

AV¼atrioventricular; SB¼sinus bradycardia.




Web Table 9 Classification of ECG observations obtained with ILR at the time of spontaneous syncope, with their

probable related mechanism (adapted from ISSUE classification w54)

AV¼atrioventricular; ECG¼electrocardiogram; SB¼sinus bradycardia.

Web Table 11 Definition of intraventricular

conduction disturbances (adapted from Surawicz

et al w111 and Zareba et al w354)

LBBB¼left bundle branch block; IVCD¼intraventricular conduction delay;

RBBB¼right bundle branch block.




Web Table 12 Inclusion criteria, design, end-points and main findings of the clinical trials evaluating the effect of

atrioventricular and interventricular delay optimization

AV¼ atrioventricular; biv.¼biventricular; DECREASE -HF¼DeviceEvaluation of CONTAK RENEWAL2 and EASYTRAK 2: Assessment of Safetyand Effectivenessin HeartFailure;

FREEDOM¼Frequent Optimization Study Using the QuickOpt Method; LV¼left ventricular; LVEF¼left ventricular ejection fraction; LVESD¼left ventricular end-systolic

dimension; LVESV¼left ventricular end-systolic volume; No.¼number of patients; NYHA¼New York Heart Association; QoL¼quality-of-life score; RHYTHM ICD

II¼Resynchronization for the HemodYnamic Treatment for Heart Failure Management Implantable Cardioverter Defibrillator II; SMART-AV¼SmartDelay Determined AV

Optimization: AComparisonto OtherAVDelayMethodsUsed inCardiacResynchronizationTherapy;VO2¼volumeof oxygen; VV¼interventricular; 6MWD¼6-minwalkdistance.CLEAR ¼Clinical Evaluation on Advanced Resynchronizati.




Web Table 19 Examples of rare inherited disorders associated with clinically significant cardiac disease

ARVC¼arrhythmogenic right ventricular cardiomyopathy; ASD¼atrioseptal defect; AV¼atrioventricular; DCM¼dilated cardiomyopathy; HCM¼hypertrophic cardiomyopathy;

PAF¼

paroxysmal atrial fibrillation; VA¼

ventricular arrhythmia; VSD¼

ventriculoseptal defect; WPW¼

Wolff-Parkinson-White syndrome.




Web Table 21 Most frequent/important

complications of PM and CRT implantation

CRT¼cardiac resynchronisation therapy; PM¼pacemaker.

Web Table 22 Suggested strategy for management of antiplatelet and anticoagulant therapy in the peri-implantation

period of PM/CRT

aDuring the minimum recommended duration of dual platelet therapbHigh risk typical setting: prosthetic valves, AF and history of stroke, intracardiac thrombus or other acute thromboembolic event, etc.

AF¼atrial fibrillation; CRT¼cardiac resynchronisation therapy; INR ¼international normalized ratio; PM¼pacemaker.




Web Table 23 Summary of randomized studies on pacing from alternative right ventricular sites

EF¼ejectionfraction; FS¼fractionalshortening; HF¼heartfailure;LV¼left ventricular; NYHA¼NewYork Heart Association; QoL¼quality of life; RVOT¼ rightventricle outflow

tract pacing; RVA¼right ventricle apical pacing; RVS¼right ventricle septal pacing.




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